Provider First Line Business Practice Location Address:
7631 W JEFFERSON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46804-4133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-436-7770
Provider Business Practice Location Address Fax Number:
260-436-3570
Provider Enumeration Date:
11/18/2005